Archive for the 'Uncategorized' category

I treat a lot of urinary tract infections. UTIs are a common problem, and as we know bacteria and resistance patterns can change. Keeping up with trends in antibiotic use and resistance isn't easy. We tend to look to our state and hospital epidemiology departments for resistance patterns, and to professional societies for official position statements. Data in my area show that E. coli has become more and more resistant to fluoroquinolone antibiotics such as cipro. We use this information to change our prescribing behavior.

The Infectious Disease Society of America recently released new guidelines that recognize this and other facts. They evaluated data on antibiotic resistance, potential side effects, and efficacy of different regimens and among the new recommendations was the elevation of an old antibiotic back to a top pick.

Nitrofurantoin (Macrobid) was used for years to treat UTIs but fell out of favor as cipro and TMP/SMX (Bactrim) became more popular. A major change in antibiotic pricing over the last few years has also favored newer, broader spectrum antibiotics. Bactrim and cipro are available free at some stores and very cheap at others.

And while the newer antibiotics may be cheap, nitrofurantoin is not. A typical course can cost $30. I tweeted this fact and to my surprise, IDSA took note. Not that they are about to change their guidelines, but the fact that they noted a concern from some blogger in the Midwest is an interesting development.

(I should note that some of this text appeared in a previous piece on an older blog of mine. The issue just won't die. --PalMD)

I've written before about many of the challenges faced by women in medicine. As more and more women enter medicine, there is a cultural shift struggling to be born. In the early 1960's, about 5% of medical American medical students were women. Now about half are. Women are first authors on more medical papers than ever, yet fill only about 11% of department chairs, and fill about 15% of full professorship positions.

There is literature studying the trends in academic and clinical medicine. But an Op-Ed piece in today's New York Times sums up nicely the barriers facing women in medicine, dragging out the same old tropes.

I frequently hear that women in medicine are likely to take time off for kids, and to work part-time, and that this somehow renders them less valuable. I'm not sure how this reasoning works. After all, doctors treat people of all ages, genders, and ethnicities, and doctors of different backgrounds often have different experiences and skills to bring to the table.

But I can see how some of these ideas are perpetuated. Slots in medical schools, residencies, and fellowships are quite limited, and it costs much more to create a doctor than tuition could ever cover. Some take a false utilitarian view that because it costs so much to create a doctor, only those who can give back the most as measured in time and money should be trained.

Residencies are limited in both the number of residents they can take, and in how many hours these residents can work. When one becomes pregnant, it can burden the entire program.

Well, this is the real world, and in the real world, half of us are women, and women are the ones who bear children. Also, the prime years for physician training are prime child-bearing years. Get used to it. If we think women have at least as much to offer as physicians as men, we better get used to the fact that they have "lady parts" and that this has real effects. Are we to limit the contributions women are allowed to make because a short period of their lives may or may not involve child-bearing?

In clinical medicine (as opposed to academic medicine), there seem to be many more opportunities to work part-time than in the past. The less you work, the less you get paid, but the pay is still pretty good. But academia is still about productivity, and gaps are not acceptable.

As a society and a profession, we have to decide to take the role of women seriously. If we demean women's role in our profession, we may be more likely to demean our female patients and family members.

We pay far too much for health care in this country, spending ridiculous amounts and getting outcomes no better than countries that spend a fraction of what we do. But most efforts at reforming the system have been aimed not toward better, more cost-effective care.

The last twenty years have seen all sorts of experiments arise in how to fund health care in the US. One thing many of these models---such as HMOs---have in common is being loathed by patients and doctors alike. It seems as if each new incarnation of private health insurance is designed solely to maximize insurance company profits rather than to deliver safe, timely, evidence-based care for which doctors are fairly compensated.

One of the experiments of the last ten years is so-called "boutique" or "concierge" medicine. In this model, patients pay their doctor a retainer and in return, the doctor takes on fewer patients and uses the reduced patient load to make herself more available to her patients. In addition to collecting the retainer, the doctor can still charge for individual visits and she or the patient can send the bill on to the insurance company.

Something about this model has always rubbed me wrong, but in truth, there appear to be few ethical problems with this model, at least in theory. However, the model requires a pool of patients willing to put out a retainer for their care. Is the care actually any better? To my knowledge, this hasn't been well-studied, but I would make an educated guess that patients are in general more satisfied, but that there is no reason to expect better medical outcomes. My diabetic patient with proteinuria should be on an ACE inhibitor whether or not I see five patients a day or twenty.

It certainly can work out well for the physician. It is much more satisfying to care for a fewer number of patients and to make money from the choice (e.g. 250 patients paying a $1500 retainer each, plus insurance reimbursement). But in the present economy, it can be difficult to recruit enough patients willing to shell out the bucks for this sort of care. Some doctors have prosed a hybrid model, in which some patients are part of the concierge patients, others standard fee-for-service or HMO patients.

This model seems fraught with ethical dangers. To have a practice where patients are inherently unequal, where a few bucks insures better treatment for some will inevitably lead to poorer care for both groups. Concierge patients may not have the access they expect (although presumably this is set out in some sort of contract), and more important "regular" patients may end up at the bottom of the to do list, having less access to their doctor, less of their time.

In a free market, a patient unsatisfied with this arrangement can walk away. But in reality, it is not always easy to find a primary care physician, and insurance and geography may place significant restraints on choice.

Given the failing model we currently have, where primary care doctors are reimbursed poorly and are forced to see increasing volumes, hybrid practices and other questionable models will keep popping up, and our already inequitable health care system will continue to divide us into haves and have-nots, with both groups encountering sub-standard outcomes and excessive costs.

In light of recent events, I'd like to repost this piece on book burning, originally from September 9, 2010. --PalMD

This week's post on book burnings spurred some interesting discussion (h/t Simon Owens). One thread of these discussions is the nature of book burning itself. From a completely ahistorical perspective, book burning is simply "speech". The burning of a book by a private citizen, or group of citizens, is simply an act of expression akin to writing an editorial or giving a speech. In the legal sense, this is probably true, and should be. Anyone should be allowed to burn a book, a flag, a cracker---anything they want in accordance with local laws (e.g. ordinances regarding such things as fire, not designed to limit speech).

But book burning has a history, a context. State-sponsored book burnings in Nazi Germany may be the most extreme manifestation, but book burning as a way to intimidate and to "erase" ideas has a long history. Just as publishing and disseminating ideas is a powerful tool, physically destroying these is both powerful and violent. While many literate people find abhorrent the idea of burning a book because of the ideas it contains, they may consider it a quirky but mostly-harmless form of expression.

It is not.

Book burning is a violent and threatening act. This isn't to say it should be outlawed, but it must be acknowledged. As with any such act, context is also important. If I were to burn a journal of mine from seventh grade, no one would care. But a pubic destruction of, say, the Qur'an is very different. It is also different from the infamous "Crackergate" of PZ Myers. Dr. Myers intentionally "desecrated" a communion wafer, and while this was offensive to many Catholics (and I found it personally distasteful) it did not create a significant threat.

Catholics are not a "despised minority" in the U.S. It is unlikely that the public desecration of something Catholic would lead to an existential threat to the Catholic population (something that was very different a century ago when Catholics, especially Irish and southern Europeans, were systematically discriminated against). This doesn't make Crackergate "OK", but it puts it on a different level in a continuum of intolerance.

Muslims, on the other had, are at risk. The anti-Muslim rhetoric in the U.S. continues to escalate, creating real fear and real harm. The planned Qur'an burning in Florida flames this hatred. It creates a real threat to a minority already under siege.

And I find hatefully disingenuous those who say, "but Muslims aren't doing enough to stop terrorism!" What is my friend and colleague who is a Muslim from Karachi supposed to do about "terrorism"? She is already against violence. Is she supposed to join the Marines? Is she supposed to give up her career and tour the country denouncing terrorism simply because someone who shares a (at least arguably) similar religious background did something bad?

Hateful, threatening acts like book burning must be called what they are: bigoted, evil, violent.

I'm currently reading Maryn McKenna's Beating Back the Devil, and her chapter on West Nile Fever really resonated with me. This is a brief reflection on my experience originally published in July, 2010. --PalMD

The Midwest loves extremes. Our spring is a quick, cold bucket of water to the face, and the fall a brief but intense set of umber and auburn brush strokes on the landscape. Today is neither of those, but still, hot, and humid enough to make breathing uncomfortable. So I'm looking out the window, rather than sitting outside, and I see something heartening: a crow.

I've noticed---really noticed---the crows and blue jays this year. Several years ago, when I was a young attending physician, the hospital seemed filled with a new ailment. The victims were often elderly, had high fevers, paralysis, confusion; they often died, or were left permanently disabled. There were younger people too, but they usually had a bad headache and a fever which resolved without incident. That's when the crows and jays died.

They died in huge numbers. On a hike with my parents, I found a dead crow lying in the middle of the path, an experience that would be repeated over and over. The bird had succumbed to West Nile Virus, as had a number of my patients.

I haven't seen a serious case of West Nile in years. I've seen suspected mild cases, but I wasn't about to do a spinal tap to find out for sure. And this year, the crows and jays are everywhere. West Nile is probably a regular part of our hot, humid summers, although we don't see the same number of severe cases that we saw in that first year. Still, when the sun sets, and the temperature becomes bearable outside, I am much more aware of each mosquito buzzing around my ankles.

I realize that it makes me sound a bit old when I say that I can't believe it's Thanksgiving....2010!, but I can't believe it. When I stayed with my sister in Chicago while interviewing for medical school, my niece was a cute little toddler. I have a picture of her sitting on my lap, laughing. This week she turned eighteen, and knows a Homo ergaster from an Autralopithecus.

A couple of years ago, my father-in-law sat at Thanksgiving dinner tired and weak. A few days later he went to the hospital and never came home.

Families change. Ours has shrunk considerably in the last few years, giving a bit of a melancholy cast to Thanksgiving. Still, I'm thankful for the family I have, and to the career I love. I'm thankful that my daughter goes out to breakfast with me and is too busy doing math problems to remember to eat her bagel. I'm thankful for a wife with more common sense in her great toe on a bad day than I've ever had at my sharpest. Despite the ups and downs of any normal life, I'm quite lucky.

Hey, folks, I have a bunch of great posts sitting in the hopper, almost done, but I have a ton of stuff to get done in meatspace that require me to enforce my first-ever blog hiatus since WCU began in May 2007. If it looks like I will need more that a brief period of time, I may end up closing up blog commenting to avoid getting clogged with spam. Thank you in advance for your patience, your reading, and your conversation.

We have some learning to do today, thanks friend of the blog, becca. The other day, I took issue with a press release published on another website. It was titled, Discovery may help scientists boost broccoli's cancer-fighting power, which I found to by hyperbolic and deceptive. The actual study being reported regarded the ability of certain compounds found in cruciferous vegetables such as broccoli to be absorbed from the cecums of rats. I dismissed the entire piece as being unsupportive of its ambitious headline.

This is a paragraph from a review article (Keck and Finley, 2004) the manuscript cites:

“Epidemiologic studies have demonstrated inverse associations between crucifer intake and the incidence of lung, pancreas, bladder, prostate, thyroid, skin, stomach, and colon cancer.3 Prospective dietary assessment of 628 men diagnosed with prostate cancer found that increasing crucifer intake from 1 to 3 or more servings per week resulted in a 41% decreased apparent risk.7 A 10-year cohort study of 47,909 men reported that increased crucifer intake, but not fruits and other vegetables, was associated with decreased risk for bladder cancer (relative risk = 0.49, 95% confidence interval = 0.32-0.75, P = .008).6″

Those numbers are simply quite solid evidence, in the context of epidemiology. Is sulphoraphane the only compound in crucifers that is important? Of course not. But this epidemiology *combined* with the cell studies you so blithely write off strongly suggest that the long term goal of the scientist you take issue with “to increase bioavailability of sulphoraphane” is, in fact, a valid pursuit.

Reading and understanding the medical literature is not an art but a skill, one that must be learned. This learning never ends. When I run into studies I'm not sure I understand, I can run questions by my colleagues both online and in real life. For me, it's always work, and I'm happy to be told when I'm wrong. Medical literature can be very different from other scientific literature, as it often focuses on risk, and reported measurements of risk can be quite deceiving (you may have to copy and paste the link address into a search engine). We also have to look at studies in the context of other studies evaluating similar questions. Because the results of medical studies often drive changes in practice that affect millions of people, we have to pay close attention to what risk and risk reduction really mean.

For this exercise, we'll focus on the two main assertions quoted by becca (the assertions are from a review article published in a somewhat questionable journal, so separating theses assertions from folklore is particularly important).

Study design is important. The type of study helps determine how association between two variables can be expressed.

The cited study is a retropective case-control study. This means that a group of patients with prostate cancer were compared to a group of similar men who did not have known prostate cancer, and they were asked to look back in time and report their intake of cruciferous vegetables over the last five years. This sort of study is vulnerable to recall bias, in which respondents' memories may not accurately reflect the truth.

Looking at the numbers from Cohen study, comparing the "most cruciferous eaters" and the "least cruciferous eaters" there is an (adjusted) odds ratio for prostate cancer of 0.59. You could say that the "broccoli" group had a 41% decreased odds of having prostate cancer compared to the broccoli-avoiders. But odds ratios are a tricky statistic and aren't intuitive. For rare diseases, odds ratios are comparable to "relative risk", a more intuitive number. But for common diseases (and prostate cancer is relatively common), an odds ratio can be deceptive. That's one of the many reasons a prospective cohort study is more useful in this case, and such a study has been done.

The study cited below by Giovannucci took a sample of tens of thousands of males who were keeping track of their eating habits and at the end of the study period compared the intake records of those who did or did not have prostate cancer. This significantly stronger study found no significant association between cruciferous vegetable consumption and the risk of developing prostate cancer (although some of the subgroup analyses were tended toward interesting).

Bladder cancer (relative risk and number needed to treat)

In the Michaud study, comparing men who ate the most cruciferous veggies to those who ate the fewest, there was, as stated, a "relative risk" of 0.49. What does this mean? It means an absolute difference in risk for bladder cancer between the two groups of 0.038%. It also means that to prevent one cancer (number needed to treat) would require 2622 person-days of high-cruciferous diet. The initial 49% relative risk sounds big, but in real cases, it's not a terribly significant number.

Compared to the prostate data, though, there is evidence from this and other prospective studies that consuming large amounts of cruciferous vegetables may have a small protective effect against the development of bladder cancers.

These subtleties are difficult, and definitely not sexy. But they are closer to reality. While it would be reasonable for me to tell patients that the sum of available data indicate that a diet higher in fruits and vegetables is probably healthier than a high-calorie, meat-based diet, there are not sufficient data for me to "prescribe" a high-cauliflower diet to prevent bladder or prostate cancer. They certainly don't allow us to assume that "broccoli has cancer-fighting power" for us to "boost". None of the studies looked at the specific use of any compound, just the use of vegetables.

It takes a long time for basic science to move into the clinic---for good reason.

India has been subjected to some pretty fierce criticism in the lead up to the Commonwealth Games being hosted in New Delhi. Organizers have been berated for shoddy construction and unsanitary athlete's quarters. Some athletes have pulled out of the games.

It only took about twelve hours for summer to turn to autumn. The air had been stifling---hot, still, humid---until quite suddenly the wind shifted to the north, changing the sound of the leaves to one that says, "You live farther north than you had remembered."

Outside my office are a couple of apple trees. No one maintains them, but the few edible apples aren't bad. Most fall to the ground, and the yellow jackets fall right after, buzzing around them greedily. They don't like to be disturbed---at all.

When the orchards open up for picking, they'll be there, too, but the apples are so good that it's worth the risk. There is no way to compare a traveling apple, days to weeks from the tree, to one snapped off the stem by my daughter. It doesn't hurt to have the fresh cider and doughnuts to go with it. The nearby cider mill opens Monday, and the smell of those doughnuts will precipitate lines of people seemingly out of nowhere.